Norway 2009: Hyllestad kommune

Introduction

Sharing knowledge is an essential part of learning in any field. Research has blossomed across the world because of international collaboration. Primary care physicians, more so in mainland Europe, have an established history of this through the forum of WONCA, EURACT and the Vasco ad Gamma movement. UK general practice, envied throughout the world, seems to have focused its efforts more on UK based educational activity. This may be highlighted by its relative inactivity in GP exchange programme. Junior UK GPs have not been proactive in European committee work.

The Junior Royal College of General Practitioner's International Committee was formed in April 2009 to respond to this deficiency and formalise communication, mainly via exchanges. I was elected to represent short-term placements to and from the UK. I decided to discover what the process of GP placement was like by going on one myself.

Throughout Europe, primary care is continuing to develop. Increasing investment is following a shift of secondary care services into the community. This is particulary the case in Norway where expenditure per person is greatest in the EEC. I have a personal affinity for Norway, having visited my partner's home in the eastern part for the last ten years or so. She speaks Bokmål Norwegian, somewhat different from the Nynorsk of Western Norway, but I had a head-start.

Sponsorship

Before I continue, I would like to thank the Tamar Faculty of the Royal College of General Practitioner's for their encouragement and sponsorship. It is of great value to have the enthusiasm of one's more experienced colleagues.

Travel & money

Of interest, I flew with Norwegian.no airlines. This is a budget airlie that flies from Gatwick to Bergen, via Oslo. Gardemoen airport outside Oslo is an impressive structure of wood, steel and glass. The exchange rate is 9.8 Krone per pound. Norway is expensive. Bottled water over 3 times the price in England. A pint of beer is now £6.12.

Hyllestad community

Norway has 19 administrative counties or Fylke. From these come 431 kommunes or municipalities. Hyllestad kommune lies in the Sogn og Fjordane flyke, north of the city of Bergen's own flyke of Hordaland. Hyllestad is region reknowned for its millstone production, as its emblem defines. Roughly 1500 people live in the region with 70% working in private business. Unemployment stands at 1.2%. Foreign workers have come in the form of labourers from Eastern Europe, teachers and doctors from Central Europe.

Hyllestad has a mayor, Torre Bradstad, who has an important administrative role. He is the head of the civil service in the commune and is involved in executive decisions regarding the development of the region. Torre was elected as a centre party member in 2007 for a 4 year term. The vision for medicine is to secure funding to provide more secondary care services in Hyllestad health centre. This may mean more GPs with specialist training.

Medicine in Norway

After medical school, over an eighteen month period, Norwegian trained doctors spend equal periods working in surgery, general medicine and general practice. Time in general practice is relatively unsupervised compared to the UK. Doctors can feel very isolated in rural Norway, responsible for public health and emergency services as well as running a general practice service. Those who elect to go into general practice can join a 5 year scheme which involves 1 year of specialist training relevant to general practice, such as rehabilitation medicine, with the remaning 4 years spent in practice. Supervision comes in the form of a regional training group that meets monthly. This does not seem to permeate through all the training years and seems quite informal. He has a form of yearly appraisal but there is no official GP membership or exam in Norway.

Practices are mainly private clinics which are funded via a limted government bursary and by a patients' payment-per-service programme. Each patient has to pay up to £174 per year. Exemptions include, children under eleven years old and those on benfits who claim back for payments rendered. A consultation with the GP costs around 132Kr (£13.50).

Host details

I found my host via google searching on the internet. Having entered the terms 'Dr', 'Norway' and 'exchange', I came across the Hippokrates database linked to the EURACT website. A contact at Bergen University passed my details to all Norwegian GPs. Dr Henrik Hoeberg was the only GP interested. Dr Hoeberg is a 36 year old Danish trained GP who came to Norway for a more civilised training schedule for primary care. Norwegian and Danish are not too dissimilar and he confesses to speak a mixture of both. He is in his final year of training, having spent his 'year out' in a institution for people with chronic fatigue. He lives with his wife (Miriam) and four children (Andreas, Annabella, Rebecca and Mia-Louisa) just outside Hyllestad. They are expecting their 5^th child.

Dr Hoeberg serves a population of 1500 with one nursing home, one school (5-18 year olds) and Førde hospital (1.5 hr drive). He is the lead on public health and is often first contact for emergencies. An emergency helicopter is up to 20 minutes away but, until the expected Seaking is operational, can be slowed by the commonly wild weather of the region. Previous emergencies include a shipbuilding incident when 3 men died of hypoxia in the carbon dioxide rich hull of a ship.

Dr Hoeberg oversees the clinical and administrative work at the practice. He offers training to the nurses. In consulting he has 20 minutes for arranged appointments and offers 10 minutes for on the day patients. He uses one hour a day for telephone appointments. Home visits are done depending on the urgency of need either during or at the end of the day.

His typical day involves consultations of patietns with the below conditions:

• Diabetes, elderly, COPD, Depression, CVS Disease, Lyme disease (Summer)

Smoking and obesity seem to be significant problems. I wondered whether Dr Hoeberg's need to maintain good rapport with his patients, affected his comfort educating those patients on lifestyle issues.

Dr Hoeberg's areas of interest are cognitive behavioural therapy (in which he has further training) and musculoskeletal medicine. He has a close working relationship with a local psychiatrist, with whom he is planning to do some primary care research into social phobia in rural Norway.

The practice

The practice has 2 doctors (one on leave), 1 nurse, 2 administrative staff and 1 health visitor. It has rooms for consulting (3), venesection/medication (1), emergency/minor procedures (1) and a health visitor room with an adjacent community room.

Practice nurse

The practice nurses seem to do less in Norway. They do not run their own clinics and are more directed by the doctor. The below list outlines their usual duties:

• Immunisations

• Dressings

• Venesection

• Drug administration

• ECG

• Wound management

Health visitor (Helsesøster)

The health visitor monitors the mother and baby from the 2nd week postnatal period. Below is a list of the Hyllestad health visitor duties:

My experience of observing a GP in Norway

Consulting

The consulting seemed patient-centred with doctor responding empathetically to cues. Dr Hoeberg places great emphasis on connecting with his patients and spends at least 10 minutes just listening at times. His manner is calm, body language open, his voice soft and his office environment is non-threatening. I was probably the only element causing distraction as I was an unexpected second opinion in the corner. Dr Hoeberg did remind me that his work depends on reputation and having rapports with his patients. However I found him to be very genuine.

His summarizing and handover was seamless and in booking all follow up himself, he safety-nets effectively. He takes the patient out to reception for payment and clarifies the plan to the receptionist. This may seem like repetition, but he feels this helps the patient understand the plan better. His housekeeping, such as writing letters seems to get done during the consultation as his IT system allows him to send letters electronically as well as enter into the patients records. He admits that paperwork for service payment does pile up and he struggles to get it done.

He allows himself a 30 minute break but is known to see people during the lunch-break if they drop in. He reflected that this was not necessarily a good routine despite the pressures to be a popular doctor. He enjoyed having me there to seek my advice but more so to facilitate his reflection which he felt he ought to more often. Overall I felt his consulting was professional and caring.

In terms of cases, I was quite surprised by his clinical decision making. He saw a case of bronchitis which he choose to x-ray rather than treat. A well child with post-viral illness persisting post-aural lymphadenopathy was sent in for blood tests, without being fully examined or having its temperature taken.

Home visits

I went on one home visit which was the most traumatic of my working life. In fact it was the most shocking experience of my life. We attended an emergency call at a farm. A gentleman had fallen through the roof of a granary store. On arrival the man was already dead at bottom of the vat, having sustained a major head trauma. The picture of blood encasing a wide eyed corpse will stay with me for a very long time.

As the various emergency services arrived, I found myself consoling the woman who found him. My Nynorsk wasn't quite adequate but my presence helped.

Later on, I needed to reflect this back to Dr Hoeberg who was quite shocked himself. Countryside accidents can be awful to attend as major trauma is often involved. He had previously attended a ship building incident where 3 men died. Life as a rural GP is not just headaches and back pain in Hyllestad.

Education

Dr Hoeberg receives updates from the Norwegian department of Health and regional social services. He attends courses free of charge within Norway and on completion can attend one course per year internationally, also for free.

The future of general practice in Norway

It seems that Norway is committed to providing a high quality of general practice rurally as there are numerous small communities not within easy reach of a hospital. It seems a place where, if you can speak Nynorsk and have a broad range of skills, you can be very valuable to the community. An increasing number of doctors from mainland Europe are electing to take their skills and experience to Norway.

Closing thoughts

I gained a fresh perspective on how doctors in Norway truly act as rural doctors used to in the UK. They need to be clinically good to manage patients away from the comfort of a local hospital. This can be stressful but exciting. They also get to know their patients very well and are more available to them. The relaxed pace of life in western Norway counterbalances this responsibility and seems to deliver a happy working life. I enjoyed the experience and felt Dr Hoeberg would be a sound contact for further Vasco da Gama visitors from the UK in the years to come.

Simon Davis

GP registrar

July 2009